Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

The effect of modified Pilates-based positions on pelvic floor electromyographic (EMG) activity; a pilot study

INTRODUCTION

The evidence regarding the effect of exercise, specifically Modified Pilates (MP), on pelvic floor muscles (PFMs) is limited. We report our pilot study using the MAPLe® device to assess the effect of MP type exercises on PFM electomyographic (EMG) activity and whether PFM contraction could be performed during specific MP exercises.

METHODS

The MAPLe® device was used to measure EMG activity of PFMs in healthy volunteers in different MP positions. Positions were divided into 'neutral', 'core' and 'plank' and EMG readings were taken at rest, during Valsalva and during active contraction.

RESULTS

Twenty volunteers were recruited. The median age was 35 (IQR 27-39.5) years. Higher EMG readings were seen in 'core' and 'plank' positions at rest. No position inhibited a conscious contraction and positions which engaged core muscles provoked an augmented contraction.

CONCLUSION

This is the first study to show that when MP positions are held for short periods of time, in asymptomatic women, the changes in PFM EMG are higher. This suggests that a stronger muscle contraction can be achieved when the core is co-contracted. Higher EMG readings were seen during 'core' and 'plank' positions; despite this, further activation with a conscious PFM contraction was still achievable.

Management of urinary incontinence

Urinary incontinence is a common problem affecting 25-45% women. Effective management can have a huge impact on a patient's quality of life and many treatments are available. Management should be dictated by the degree of bother the symptoms are having, and vary depending on the type on incontinence. Conservative measures should always be initiated, including optimisation of body mass index and smoking cessation. Overactive bladder and urge urinary incontinence can be improved with bladder retraining and avoidance of bladder stimulants. Medical treatment then includes anticholinergic medications or Mirabegron. More invasive options include Botulinum Toxin A (Botox®) injections, sacral nerve stimulation or urological surgery. Stress urinary incontinence should be managed initially with pelvic floor exercises, and input from a specialist nurse or physiotherapist is beneficial. The surgical options for managing stress incontinence have changed considerably over the years, but include bladder neck injections, mid-urethral slings, colposuspension or autologous fascial slings. Mixed urinary incontinence is more challenging to manage, but all conservative measures should be started. Further treatment is directed towards the predominant symptom, but overactivity should be controlled before surgical measures for stress urinary incontinence are performed.

Living in warmer, more acidic oceans retards physiological recovery from tidal emersion in the velvet swimming crab, Necora puber

The distribution patterns of many species in the intertidal zone are partly determined by their ability to survive and recover from tidal emersion. During emersion, most crustaceans experience gill collapse, impairing gas exchange. Such collapse generates a state of hypoxemia and a hypercapnia-induced respiratory acidosis, leading to hyperlactaemia and metabolic acidosis. However, how such physiological responses to emersion are modified by prior exposure to elevated CO2 and temperature combinations, indicative of future climate change scenarios, is not known. We therefore investigated key physiological responses of velvet swimming crabs, Necora puber, kept for 14 days at one of four pCO2/temperature treatments (400 μatm/10°C, 1000 μatm/10°C, 400 μatm/15°C or 1000 μatm/15°C) to experimental emersion and recovery. Pre-exposure to elevated pCO2 and temperature increased pre-emersion bicarbonate ion concentrations [HCO3(-)], increasing resistance to short periods of emersion (90 min). However, there was still a significant acidosis following 180 min emersion in all treatments. The recovery of extracellular acid-base via the removal of extracellular pCO2 and lactate after emersion was significantly retarded by exposure to both elevated temperature and pCO2. If elevated environmental pCO2 and temperature lead to slower recovery after emersion, then some predominantly subtidal species that also inhabit the low to mid shore, such as N. puber, may have a reduced physiological capacity to retain their presence in the low intertidal zone, ultimately affecting their bathymetric range of distribution, as well as the structure and diversity of intertidal assemblages.

Glutaraldehyde-tanned microvascular grafts

In this study the efficacy of preserving microvascular heterografts with glutaraldehyde tanning was investigated. These were compared with glutaraldehyde-tanned autografts. Previous studies have found that untreated autograft veins maintain a 95% patency rate, whilst untreated heterograft veins (Group 1) had a 15% patency rate at 4 weeks in this study. Autogenous glutaraldehyde-tanned rabbit carotid arterial grafts (Group 2) and glutaraldehyde-tanned human chorionic veins (Group 3) were interposed in rabbit femoral or carotid arteries. Fifty per cent and 75% patency rates were achieved respectively at 4 weeks. The low patency rate of the autogenous group suggests that the glutaraldehyde tanning technique itself is largely responsible for the low patency of glutaraldehyde-tanned human chorionic veins rather than any immunological response. Therefore if human chorionic veins are to be used as a readily available preserved microvascular graft, further investigation is required to develop another technique which will reduce antigenicity without promoting thrombosis.

Scanning electron microscope study of microvenous grafts to artery

The healing of microvenous grafts to femoral arteries in the rabbit has been studied using scanning electron microscopy at intervals ranging from zero time to 5 months. Healing of the grafts followed a similar pattern to that of end-to-end repairs. Postoperative survival of the original endothelium was far superior in the vein than in the artery. Re-endothelialization was completed by 2 weeks. No dilation of the graft or aneurysm formation appeared. A detailed account of the healing vein grafts has been reported and will enable comparison of healing of microvascular heterografts.

Segmental microvenous graft to artery

One hundred and five microvenous grafts were carried out during three periods of time. Forty-five were performed in 1971, 25 were performed in 1975 and 35 were performed in 1979. The rabbits weighed 2 to 2.5 kg and a standard technique was followed by inserting a 1 cm vein graft after creating a defect of 0.5 cm in the femoral artery, taking the graft from the femoral vein on the same side. Exploration was carried out from 1 to 21 weeks at weekly intervals. The patency rate in Series I (1971) was 71 per cent, whereas the patency rate in Series II (1975) was 96 per cent and in Series III (1979) was 100 per cent. The scanning electron microscope showed that in the short term there was no narrowing of the lumen, nor any microaneurysm formation as reported previously by Buchler and Buncke (1979).

Lymphaticolymphatic anastomosis

Lymphaticovenous anastomosis has proved valuable in the treatment of obstructive lymphedema. Histological studies of this anastomosis have shown the lymphatic component to be almost inactive in anastomotic healing. In order to clarify the role of the lymphatics, experimental lymphaticolymphatic anastomoses were performed in canine femoral lymphatics. The technique developed calls for eight to ten 19 mu sutures to prevent vessel wall collapse, and preservation of the vasa vasorum. Vessels were harvested from one hour to six weeks after anastomosis. Scanning electron microscopy and conventional light histology revealed the lymphatics to have active healing of the intima with complete reendothelialization by two weeks. The techniques developed in this study are directly applicable to human lymphaticovenous anastomosis.

Relationship between lymphocyte emigration and vascular endothelium in chronic inflammation

Small blood vessels within areas of chronic inflammation which contain large numbers of lymphocytes develop unusually thick walls. Combined histological and electron microscope study shows that the thickening is due to hypertrophy of endothelial cells which come to resemble the endothelium of post-capillary venules in lymphoid tissue. Vessels of this type have been found in experimental granulomas induced by injection of Freund's adjuvant or killed tubercle bacilli and in human biopsy material from cases of rheumatoid arthritis and Hashimoto's disease of the thyroid. Comparison with the developing Peyer's patch in young rats shows that the unusual vessels in granulomas are very similar in endothelial cell size, pattern of distribution, extent of lymphocyte migration and degree of carbon leakage to post-capillary venules of the immature Peyer's patch. Study of the time at which lymphocytes appear in large numbers within the granuloma or developing Peyer's patch and the time at which thickened vessels are first seen suggest tha the endothelial changes are a consequence and not a cause of lymphocyte emigration. The stimulus to endothelial hyperthrophy appears to be massive sustained migration of lymphocytes, but the functional significance of this change in vascular structure is not clear.